Dr Lydia Morgan
BVM BVS BVMedSci MRCVS
VVS Commercial Manager
Dr Debra Agapito DVM DipACVO, MRCVS part of the VVS Ophthalmology Specialist team, was called by one of our VVS member practices to assess Dumble, a 1 year-old female neutered DSH.
Dumble had been with her new owners for 8 months and shared the house with another cat. The owners had noticed waxing and waning blepharospasm of her left eye for several months. Neither of the cats in the household had any history of respiratory disease, but Dumble was reported to have been successfully treated for conjunctivitis as a kitten in her left eye. Recent examination by her referring veterinarian identified lesions in the anterior segment of Dumble’s left eye. She was treated with topical Polymixin B/Dexamethasone suspension for one month. Dumble’s blepharospasm improved but deteriorated again once topical medication ceased. At the time of the examination she was not on any medication.
Dr Agapito initially spoke with Dumble’s vet to discuss the case. Together, they decided that a virtual live-guided consultation would be the most appropriate next step as still images were non-diagnostic.
Using the VVS virtual platform, Dr Agapito guided Dumble’s vet through a thorough ophthalmic examination of intra-ocular pressures, Schirmer tear testing (STT), and a neuro-ophthalmic examination which included; palpebral reflex, menace response, dazzle reflex and direct and indirect pupillary light reflex. These were all normal.
Whilst examining the left eye and surrounding structures Dr Agapito noticed blepharospasm and a moderate lower eyelid entropion. Topical anaesthetic was instilled in the left eye, and although ocular comfort improved the entropion remained. Her right eyelids appeared unremarkable at this time.
The anterior segment of the left eye was the next ocular structure examined by the referring vet with Dr Agapito guiding the examination virtually. Multifocal persistent pupillary membranes (PPM) extending from the mid-iris to the anterior lens capsule were seen. An area of pigmentation was also noted on the anterior lens capsule which was associated with the PPMs. An incipient cataract was also identified. Incipient cataracts are early opacities that affect less than 15% of the lens and typically do not affect vision.
PPM’s are remnants of the foetal blood supply to the lens which have not resorbed (usually resorb by 6 weeks of age). They are not progressive; however, because they are attached to the lens, Dumble’s cataract has the potential to progress over time. This is something that will need to be monitored.
Left: Finger-like projections from the iris are the Persistent pupillary membrane’s extending from the middle of iris plane to anterior lens capsule.
Right: Opacity to the lens showing Dumble’s Incipient cataract. This is affecting less than 15% of the lens structure.
Following examination of the anterior chamber, the retina and lens were examined in the right eye and these appeared normal.
Once Dr Agapito and the referring vet were happy that all suitable images of the anterior chamber, lens and retina had been achieved in both eyes, Fluorescein stain was applied bilaterally. Mild positive epithelial deficits were noted in both eyes- these were linear and associated with the STT testing strips. It is not unusual to see mild positive fluorescein uptake following STT.
Additionally, positive wicking of fluorescein along the inferior lateral to mid-eyelid was seen in the left eye which wasn’t present in the right eye.
Following the ophthalmology examination, Dr Agapito summarised all of the findings with the referring vet and together they decided on an appropriate plan for Dumble’s care going forward.
Dumble has lower eyelid entropion, secondary to a longer than normal lower eyelid (megablepharon) which is causing some corneal epithelial damage in the temporal cornea. Cats with entropion can be more of a challenge to repair compared to dogs. Dr Agapito recommended that the entropion repair be performed by a specialist ophthalmologist. Owners were advised, based on current research, there is a chance (17%) that over time Dumble may also develop entropion in her right eye.
The persistent pupillary membranes (PPMs) were an incidental finding, but the incipient cataract associated with these would require further monitoring in the future for any progression. Re-examination in 6 months was recommended with Dr Agapito or sooner if ocular signs warrant.
Whilst awaiting surgery it was recommended that Dumble started on topical ocular lubrication to help protect the ocular surface and improve ocular comfort.
Throughout the consultation, Dumble’s vet could see and speak to Dr Agapito via the VVS platform. Dr Agapito could see exactly what Dumble’s vet was seeing in real-time and in high definition format. They could both share screens and hear each other clearly via VVS’s integrated technology system. Together they were able to diagnose Dumble’s problem and provide truly excellent and holistic care for Dumble. Dumble’s vet was at all times integrally involved in the case work-up. This enabled the vet to improve their ophthalmology skills and knowledge. This also helped to reassure Dumble’s owners that Dumble was being cared for by the vet they know and trust, in a practice they are familiar with. Dumble’s vet will receive a CPD certificate documenting the time spent working directly with Dr Agapito as one-to-one personalised CPD.
Dumble’s vet can contact Dr Agapito for further advice at any point. By having the VVS workstation in the practice the referring vet and their team not only have access to world-class ophthalmology specialists, they also have access to a multi-disciplinary specialist team.
Benefits of the VVS Virtual system include:
- Patients receive world-class specialist care.
- Patients are treated in their usual practice, by vets that know them and their owners.
- Patients and owners do not have to travel to referral centres.
- Vets keep cases (and revenues) in house.
- Vets are upskilled, as they learn from working directly with VVS Specialists.
- Time spent working under the guidance of a VVS Specialist counts towards CPD hours, meaning that vets gain CPD whilst also bringing in practice revenue and without having days away from the practice.
- Vets have reassurance that they never need to work alone as VVS’s friendly Specialists become part of the practice team.
- Current social distancing guidelines are easy to follow as all specialist consults are virtual.